Fillable UT Tyler Respiratory Hazard Evaluation Form (University of Texas at Tyler)

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UT Tyler Respiratory Hazard Evaluation Form (University of Texas at Tyler)

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The UT Tyler Respiratory Hazard Evaluation Form (University of Texas at Tyler) form is 1 page long and contains:

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  • 45 check-boxes
  • 18 other fields

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File type: PDF

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UT Tyler Respiratory Hazard Evaluation Form
Respiratory Hazard Assessment
Department:
Date:
Location where task occurs:
Please provide a detailed description of the job task:
What is the expected physical work effort:
Light/Sedentary
Moderate
Strenuous
Employees Names:
Supervisor name:
JHA?
Exposure to chemicals:
Formaldehyde/Formalin
1
Mercury vapors
Methylene Chloride
Pesticides
Ammonia
Acid gas (e.g. hydrogen chloride, hydrogen sulfide)
Organic Vapors (e.g. benzene, toluene, MEK, acetone, xylene, paint thinners)
Other:
! Please approximate how many days/min/quantity used
:
Exposure to dust, mist, fumes or particulates:
Asbestos
Lead
Welding fumes
Asphalt fumes
Other fumes:
Cotton dust
Grain dust
Animal dust
Wood dust
Pesticide application
Paint spraying
Biological hazards (list):
Nanoparticles
1
(list):
Other:
! Please approximate how many days/min/quantity used
:
Work involving any of the above mentioned hazards is performed:
Outside
In a fume hood/Biosafety Cabinet
In the lab (bench top)
In the shop
In a spray paint room or booth
In a mechanical room
In confined space
1
In an oxygen deficient atmosphere
1
Other:
Type of respirator recommended:
N, R, or P disposable respirator e.g., N95, P100
(filter mask, non-cartridge type only)
Half facepiece (negative pressure) respirator
Full facepiece (negative pressure) respirator
Powered-air purifying
respirator (PAPR) tight fit
Powered-air purifying
respirator (PAPR) loose fit
Self-Contained Breathing Apparatus (SCBA)
Supplied-air respirator/Airline
None
Type of filter/cartridge currently in use (include color of label):
Hazard concentration:
Unknown
Known (please provide sampling data)
•
Form can be sent by email to safety@uttyler.edu or hard copy can be mailed to:
1
Work performed in these environments require an exposure risk assessment. Please contact EHS at (903) 566-7011.
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UT Tyler Respiratory Hazard Evaluation Form (University of Texas at Tyler)

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Completed 24 July 2020

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